I remember, not long ago, seeing many children with ear infections every day I was in the office – children that were often up screaming the night before. Today it’s not surprising to go an entire day in clinic without seeing a single one.

Visits to doctors’ offices for ear infections more than doubled between 1975 and 1990, from about 10 million per year to about 25 million per year. They kept increasing through about 1994, when they started to decline steadily by about 5% per year, now at their lowest level in three decades.

Over thirteen years, office visits for ear infections in kids under age 6 dropped from about 640 visits per 1000 children per year to about 380 visits. The drop for hospitalized children being diagnosed with an ear infection is even steeper. And the annual price tag for ear infection treatment in the US has fallen by about $2 billion.

Why the dramatic disappearance?

Several things have changed since the early 1990s. Air pollution, linked to ear infections, fell significantly after the Clean Air Act of 1990. Breastfeeding, protective against ear infections, increased modestly from less than 2/3 of babies starting on mother’s milk to more than ¾ today. A vaccine that may help prevent some ear infections came into wide use in 2002.

But the strongest link, according to a May 2011 study from researchers at Harvard University, came from a drop in tobacco smoke inside children’s homes. We’ve known since the 1990’s that exposure to second hand smoke causes millions of ear infections every year. In 1993, most US children were still exposed to tobacco smoke in their own home. Today only 14 percent of kids live in a home where smoking is allowed inside – a change big enough to account for the difference.

Four thoughts for responding to this good news.

1. If you smoke, smoke outside.
2. Keep the air in your home fresh. Avoid cleaners with harsh fumes. Consider houseplants to clean the air. Open windows when practical.
3. Given the option, breast feed. After weaning, choose foods that support healthy gut bacteria.
4. If your child does get an ear infection, choose a gentle treatment first, if appropriate. Antibiotics are wonderful, when needed, but each time they are given it makes another ear infection more likely. With more resistant bacteria.

Alpert HR, Behm, I, Connolly GN, Kabir Z. “Smoke-free households with children and decreasing rates of paediatric clinical encounters for otitis media in the United States.” Tobacco Control. May 2011; 20:207-211.

Bhattacharyya N and Shapiro NL. “Air quality improvement and the prevalence of frequent ear infections in children.” Otolaryngology – Head and Neck Surgery. Feb 2010; 142:242-246

Clindamycin is strong antibiotic used to treat difficult bacterial infections in children. You might see a brand name such as Cleocin on the label. It comes as liquid or capsules, and is also available as an injection or IV antibiotic.

Serious diarrhea is possible while taking in this antibiotic or during the months afterwards. This should be reported to your healthcare provider right away as treatment may be needed.

While giving clindamycin (or other antibiotics), consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

This medicine should be taken with a full glass of water.

Liquid clindamycin should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). It may be stored at room temperature. Do not keep the liquid in the refrigerator. Discard any unused clindamycin 14 days after it was first prepared by the pharmacist.

Clindamycin is a recommended for children with ear infections that have not improved after 48 to 72 hours on another antibiotic and who are allergic to amoxicillin. It is usually given three or four times daily.

If your child is taking clindamycin for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss other options.

Do Not use clindamycin if your child is known to be allergic to this or to any similar antibiotics such as lincomyin. Do not give clindamycin together with erythromycin. Be sure the prescribing doctor knows if your child has any other medication allergies, or has kidney disease, liver disease, intestinal disease, asthma, or eczema. Be sure to report any other medicines your child might be taking.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.

Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.

Clarithromycin is an antibiotic used to treat many different types of bacterial infections in children. You might see a brand name such as Biaxin on the label. It comes as liquid, tablets, or extended release tablets.

The extended release tablets should be taken with food, but the other forms are fine to take either way. If you find it upsets the stomach, taking it with food may help. Clarithromycin should be taken at least two hours before any antacids that contain magnesium or aluminum, because these can interfere with the absorption of the antibiotic.

Liquid clarithromycin should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). It may be stored at room temperature. Do not keep the liquid in the refrigerator. Discard any unused clarithromycin 14 days after it was first prepared by the pharmacist.

Clarithromycin is a recommended first antibiotic for some children with ear infections who are allergic to amoxicillin. It is usually given twice daily, but the extended release form may be given once daily.

If your child is taking clarithromycin for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to another antibiotic, such ceftriaxone or clindamycin.

Do Not use clarithromycin if your child is known to be allergic to this or to any similar antibiotics such as azithromycin or erythromcyin. Other antibiotic options might include ceftriaxone, or clindamycin. Be sure the prescribing doctor knows if your child has any other medication allergies, or has kidney disease, liver disease, or a heart rhythm problem. Be sure to report any other medicines your child might be taking.

Diarrhea is a common side effect of antibiotics. Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

^{AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.
Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.}

Cefdinir is an antibiotic used to treat many different types of bacterial infections in children. You might see a brand name such as Omnicef on the label. It belongs to the cephalosporin family of antibiotics (“cousins” to the penicillins). This antibiotic comes as strawberry and cream flavored liquid or as capsules.

Either form can be given with or without food. However, cefdinir should be taken at least two hours before any multivitamins with iron, iron supplements, or antacids that contain magnesium or aluminum, because these can interfere with the absorption of the antibiotic. Infant formula with iron does not pose a problem.

Liquid cefdinir should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). It may be stored at room temperature. Discard any unused cefdinir 10 days after it was first prepared by the pharmacist.

Cefdinir is a recommended first antibiotic for some children with ear infections who are allergic to amoxicillin. It can be taken once or twice a day. Taking the dose once a day is usually as effective as dividing the dose in two, but the smaller doses may be gentler on the stomach. If you happen to miss a twice-a-day dose, you can go ahead and give it late, but try not to give once-a-day doses within about 12 hours of each other. If you happen to give too much at once (more than two doses), seek medical advice.

If your child is taking cefdinir for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to another antibiotic, such ceftriaxone or clindamycin.

Do Not use cefdinir if your child is known to be allergic to this or to any of the cephalosporin antibiotics, such as cephalexin, cefuroxime, or ceftriaxone. Other antibiotic options might include azithromycin, clarithromycin, or clindamycin. Be sure the prescribing doctor knows if your child has any other medication allergies (especially to penicillins), or has kidney disease, intestinal problems. Be sure to report any other medicines your child might be taking.

Diarrhea is a common side effect of antibiotics. Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.

Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.

Amoxicillin-clavulanate is a strong combination antibiotic used to treat many different types of bacterial infections in children. The clavulanate makes it difficult for some resistant bacteria to withstand the amoxicillin, resulting in a very powerful antibiotic. Nevertheless, it does not help in viral infections such as a cold or flu.

This common antibiotic comes both as liquid and as chewable, regular, or extended release tablets. You might see a brand name such as Augmentin on the label. Different forms contain different proportions of clavulanate and aren’t simply exchangeable with each other at the same dose of the amoxicillin portion (e.g., a 400 mg tablet is not the same dose as 400 mg of liquid).

No matter which form of amoxicillin-clavulanate you use, it’s usually best to take the medicine at the start of a meal to reduce stomach upset. The tablets also should be taken with a full glass of water. The chewables should be chewed thoroughly before swallowing; the other tablets should not be chewed so that the medication is released in the body at the appropriate rate.

Liquid amoxicillin-clavulanate should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). Store it in the refrigerator between doses. It should not be allowed to freeze. Discard any unused amoxicillin-clavulanate 10 days after it was first prepared by the pharmacist.

Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day).1 Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Amoxicillin-clavulanate is the recommended first choice antibiotic for most children with severe ear infections who have high fevers and/or severe ear pain. It’s also recommended for most children with ear infections whose first antibiotic didn’t improve the symptoms within 48 to 72 hours.²

If you happen to miss a dose, you can go ahead and give it late – but try not to do two doses within about four hours of each other. If you happen to give too much at once (more than two doses), seek medical advice.

If your child is taking amoxicillin-clavulanate for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to another antibiotic, such as ceftriaxone.

Do Not use amoxicillin-clavulanate if your child is known to be allergic to clavulanate, to amoxicillin, or to any of the penicillin-type antibiotics. Depending on the type of allergy, other antibiotic options might include ceftriaxone or clindamycin. Sometimes a non-itchy rash is a side effect of taking amoxicillin, and not an allergic reaction. If your child has had a rash with amoxicillin, discuss this possibility with your doctor.

Be sure the prescribing doctor knows if your child has any other medication allergies, or has mono, asthma, liver or kidney disease, or a bleeding problem. Be sure to report any other medicines your child might be taking.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat. Black hairy tongue, a fairly common temporary side effect of amoxicillin, is not an allergic reaction.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

Ceftriaxone is a broad spectrum antibiotic that can be given by injection. It’s used to treat many different types of bacterial infections in children and is sometimes called by the brand name Rocephin. It belongs to the cephalosporin family of antibiotics (“cousins” to the penicillins). This antibiotic is only given as a shot or in an IV: it does not come in an oral form.

Ceftriaxone is a recommended first antibiotic for some children with severe ear infections who are allergic to amoxicillin and who have a high fever or severe ear pain. A child might receive one shot or three shots (one a day). Three daily shots might also be recommended as a stronger choice for a child who still has symptoms after 48 to 72 hours of another antibiotic, especially if there is a fever or severe ear pain.

If your child is given ceftriaxone for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss more ceftriaxone shots, switching to another antibiotic, or draining the fluid in the ear.

Do Not use ceftriaxone if your child is known to be allergic to this or to any of the cephalosporin antibiotics, such as cephalexin, cefuroxime, or cefdinir. Other antibiotic options include amoxicillin-clavulanate or clindamycin. Be sure the prescribing doctor knows if your child has any other medication allergies (especially to penicillins), or has kidney disease, liver disease, intestinal problems, or gallbladder disease. Be sure to report any other medicines your child might be taking.

Diarrhea is a common side effect of antibiotics. Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.

Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.

Cefuroxime is an antibiotic used to treat many different types of bacterial infections in children. You might see a brand name such as Ceftin on the label. It belongs to the cephalosporin family of antibiotics (“cousins” to the penicillins). This antibiotic comes as tutti-frutti flavored liquid or as tablets. According to the manufacturer, only 5 percent of children complain about the taste of the liquid. Those who can swallow the tablets generally have no taste complaints; crushed tablets, though, taste very bitter.

If a child switches from liquid to tablets or vice versa, the milligram doses may be different: the two forms are not equivalent to each other.

Cefuroxime tablets may be taken with or without food. However, cefuroxime liquid should be taken with food. Liquid cefuroxime should be shaken before giving each dose. To get the correct dose, skip the silverware spoon and use a measuring spoon or dose-measuring device (ask your pharmacist for one if you don’t have one). It must be stored in a refrigerator. Discard any unused cefuroxime 10 days after it was first prepared by the pharmacist.

Cefuroxime is a recommended first antibiotic for some children with ear infections who are allergic to amoxicillin. It is given twice a day. If you happen to miss a dose, you can go ahead and give it late, but try not to give doses within about four hours of each other. If you happen to give too much at once (more than two doses), seek medical advice.

If your child is taking cefuroxime for an ear infection, you should expect improvement within 48 to 72 hours. If not, contact your doctor to discuss switching to another antibiotic, such ceftriaxone or clindamycin.

Do Not use cefuroxime if your child is known to be allergic to this or to any of the cephalosporin antibiotics, such as cephalexin, cefdinir, cefpodixime, or ceftriaxone. Other antibiotic options might include azithromycin, clarithromycin, or clindamycin. Be sure the prescribing doctor knows if your child has any other medication allergies (especially to penicillins), or has kidney disease, liver disease, intestinal problems, or diabetes. Be sure to report any other medicines your child might be taking.

Diarrhea is a common side effect of antibiotics. Whenever antibiotics are given, consider also giving your child probiotics (beneficial bacteria). Out of ten well-designed studies, nine showed significantly less diarrhea in the children receiving probiotics (the studies used between 5 and 40 billion cfu per day). Probiotics are available as supplements or in some foods and beverages (yogurt, kefir, juice). Whatever you choose, look for at least 5 billion colonies.

Get emergency care if your child is showing signs of a serious allergic reaction, such as difficulty breathing, spreading hives, or swelling of the lips, tongue, or throat.

Other side effects are possible with this or any medication. Be sure to report unexpected new symptoms to your healthcare provider. Whether they are caused by the antibiotic or by the illness getting worse, unexpected symptoms are important to report.

AAP Clinical Practice Guideline. Diagnosis and management of acute otitis media. Pediatrics, May 2004, 113(5):1451-1465.

Johnston BC, Supina AL, Ospina M, Vohra S. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub2.

Most kids would go out of their way to avoid eating garlic or onions, yet it is not unusual for a child to wake up with very smelly breath. Throughout the day, a child’s saliva, swished by the mouth muscles, washes away unwanted debris. As soon as a child falls asleep, saliva production plummets, and the muscles relax. The longer a child sleeps, the higher the bacterial count in the mouth rises, resulting in “morning breath.”

In children, smelly breath that persists throughout the day is most often the result of mouth-breathing, which dries out the mouth and allows the bacteria to grow. Children who consistently breathe through their mouths might have colds, sinus infections, allergies, or enlarged tonsils or adenoids blocking the nasal passages, so again, a visit to the pediatrician is in order. Thumbsucking or sucking on a blanket can also dry out the mouth.

To improve most cases of bad breath, the goal is to decrease mouth bacteria and increase saliva. The better your child’s toothbrushing technique, the smaller number of bacteria will be present. Make after-meal brushing a habit. Use a timer to help maintain brushing for at least two minutes. Be sure he or she brushes her tongue. You might also try a rotary electric toothbrush. I do not recommend mouthwashes or fluoride rinses in children, since kids tend to swallow them. Breath mints may mask the problem, but don’t get at the source. As your child gets older, sugarless sour candy or sugarless chewing gum can get the saliva flowing and get those mouth muscles moving.

If the mouth odor problem persists, she or he should see a physician. Bad breath in children that doesn’t respond to the above measures should be investigated.

It’s time to add a new habit to pet care. The Centers for Disease Control and Prevention have traced a lingering 19-state Salmonella outbreak to the handling of dry dog food and dog treats. There have been seventy laboratory-confirmed cases of Salmonella was found in opened bags of dry dog food, in unopened bags, in stool from those dogs, and in one manufacturing plant. The pet food plant at the center of this outbreak produces 25 different brands of dry pet food. This source has been cleaned up, but similar outbreaks are likely to recur. In fact, this has probably been an unrecognized source of infection for many years.

The take home message is that dry pet food, pet treats, and supplements made from animal products should be handled as if they were raw meat. This means washing your hands with soap and water for at least 20 seconds after handling pet food, or using an instant hand sanitizer. The hands should be cleaned before eating or putting the hands in the mouth. Exploring babies should be kept away from pet feeding areas, and kids under five years old shouldn’t have access to pet foods unless an adult is sure to catch them before they put their hands in their mouths.

Center for Disease Control and Prevention. Multistate Outbreak of Human Salmonella Infections Caused by Contaminated Dry Dog Food — United States, 2006—2007. Morbidity and Mortality Weekly Report. May 16, 2008,

If fluid from the middle ear space is draining out of the ear in a child with an acute ear infection (acute otitis media), there must be an opening in the eardrum – the air-tight membrane that separates the middle ear from the ear canal and helps us to hear. If fluid can get out through this opening, then it makes sense that medicine might get in. Researchers at the Children’s Hospital of Pittsburgh evaluated 80 children who had acute otitis media that was draining through ear tubes that the children already had in place. Half of the children received strong oral antibiotics, twice a day for ten days; the other half received antibiotic drops directly in the ear, twice a day for seven days. Those who got oral antibiotics received about 1000 times more antibiotic than those who got the drops: 90mg of antibiotics for every kg of body weight daily (the average age child in the study would weigh a little more than 12 kg, so over 900 mg daily total); those who received drops received only 0.84 mg total every day, whether they weighed 8 kg or 38 kg.

The results appeared September 2006 in Pediatrics. Even though the drops delivered 1000 times less antibiotics, they went straight to the source of the infection, rather than being spread throughout the body. The drops were more than 25% more likely to clear the infection entirely. The drops worked on average 42% faster. The drops had dramatically fewer side effects (there was an almost 30% side effect rate from the oral antibiotics!). Beyond all of this, I am most concerned that about 10% of the patients who took oral antibiotics had already acquired new bacteria in the ear during treatment; new bacteria did not emerge in any children who received drops. Antibiotic drops worked better, faster, with fewer side effects, and less risk of developing bacterial resistance. I can’t see why for most kids with a draining ear you would choose oral antibiotics as the first line of treatment.